The “straighten pigtail” technique for selective replacement of a pigtail plastic stent

In cases of malignant hilar biliary obstruction (MHBO), a biliary stent should be selectively placed in the biliary branch where the drainage effect is most expected on the basis of preoperative imaging studies. Thus, stent replacement or conversion to a metal stent should be performed in the bile duct where the stent was previously placed [1] [2] [3].

For stent replacement, the snare-over-the-guidewire (SOG) technique is reportedly useful for hilar biliary stenosis [4] [5]. However, the SOG technique is limited to straight plastic stents and cannot be performed with pigtail plastic stents, which are often used for MHBO – so there is a gap between usefulness and general usability.

Herein, we report a modified SOG technique, the “straighten pigtail” technique, that can be used for pigtail plastic stents.

A 78-year-old man with MHBO required replacement of a pigtail plastic stent inserted in the right posterior branch. During the initial drainage treatment, manipulation of the guidewire to the right posterior branch was challenging; therefore, a safe and reliable replacement method was desired.

First, a catheter was integrated and advanced through the scope to the duodenum ([Fig. 1]). Then, a 0.025-inch angled guidewire was inserted into the pigtail portion of the stent lumen and advanced with rotational torque to successfully insert it into the bile duct where the plastic stent had been inserted ([Fig. 2]).

Fig. 1 A 0.025-inch angled guidewire is inserted into the pigtail portion of the stent lumen.

Fig. 2 The guidewire is advanced with rotational torque and successfully inserted into the bile duct where the plastic stent is inserted.

Next, a snare was inserted through the catheter and the tip of the pigtail portion was grasped ([Fig. 3]). The pigtail portion was then carefully pulled into the scope and straightened ([Fig. 4]). This straightening enabled the removal of only the plastic stent while leaving the guidewire, and thus “selective” stent replacement was successful ([Fig. 5], [Video 1]).

Fig. 3 A snare is inserted through the catheter and the tip of the pigtail portion of the plastic stent is grasped.

Fig. 4 The pigtail portion is carefully pulled into the scope and straightened.

Fig. 5 This straightening makes it possible to remove only the plastic stent while leaving the guidewire.

This “straighten pigtail” technique ensures accuracy and ease in the replacement of pigtail plastic stents. This can be a useful option not only in MHBO cases but in daily practice as a selective stent replacement technique for pigtail plastic stents.

Video 1 Demonstration of the “straighten pigtail” technique in selective replacement of a pigtail plastic stent in a 78-year-old patient with hilar malignant biliary obstruction.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Takenaka M, Kudo M. Current status of endoscopic re-intervention for hilar malignant biliary obstruction. Dig Endosc 2021; 33: 746-748
• 2 Takenaka M, Yamazaki T, Otsuka Y. et al. Successful use of two guidewires with different properties using a double-lumen catheter for postoperative biliary stricture. Endoscopy 2022; 54: E190-E192
• 3 Takenaka M, Yamazaki T, Otsuka Y. et al. Across-the-papilla side-by-side placement of 6-mm fully covered metallic stents for malignant hilar biliary obstruction: a novel concept that may facilitate reintervention. Endoscopy 2022; 54: E102-E105
• 4 Fujita N, Sugawara T, Noda Y. et al. Snare-over-the-wire technique for safe exchange of a stent following endosonography-guided biliary drainage. Dig Endosc 2009; 21: 48-52
• 5 Yoshida A, Takenaka M, Takashima K. et al. Usefulness of the novel snare-over-the-guidewire method for transpapillary plastic stent replacement (with video). J Clin Med 2021; 10: 2858

Publication History

Article published online:
01 September 2022